Clinical Appeals Nurse Reviewer

Blue Cross Blue Shield of Massachusetts, Inc.; Hingham (MA); Remote; USD 80,000 - 100,000; Full time

Job summary

A leading company is seeking a Clinical Appeals Nurse Reviewer to oversee provider and member appeals for denied services. Candidates must have an active Massachusetts RN license and a strong background in clinical judgment. This remote-friendly role emphasizes collaboration with various healthcare teams and requires excellent communication and organizational skills. Join a progressive team dedicated to transforming healthcare while enjoying a comprehensive benefits package.

Benefits

Paid time off

Medical/dental/vision insurance

401(k) benefits

Well-being benefits

Qualifications

• Active RN license in Massachusetts required.
• 3-5 years clinical care experience needed.
• Strong verbal and written communication skills.

Responsibilities

• Review provider and member appeals using clinical judgment and guidelines.
• Collaborate with Physician Review Units for medical necessity.
• Research and respond to appeal requests per regulatory standards.

Skills

Clinical judgment

Communication

Organizational skills

Education

Registered Nurse with active Massachusetts license

Associate's Degree in Nursing (ADN)

Bachelor's Degree in Nursing (BSN)

Tools

Healthcare delivery systems knowledge

Computer skills

Job description

Ready to help us transform healthcare? Bring your true colors to blue.

The Role
The Clinical Appeals Nurse Reviewer is responsible for applying sound clinical judgement to review provider and member appeals for denied services according to appropriate guidelines. This position requires strong clinical judgment, ability to analyze medical records and apply medical knowledge to make the most appropriate decision within regulatory timeframes.

The Team
As an integral part of the Appeal Review team, the Clinical Appeals Nurse Reviewer will serve as a liaison and business expert for member and provider submitted appeals. Working collaboratively with Physician review unit, Utilization Management, Case Management, Member appeals and Grievance, Provider Service, Claims, Network Management, and Medical Policy teams.

This role is eligible for our eWorker persona (remote).

Key Responsibilities:

• Review provider and member appeals utilizing sound clinical judgement, medical policy, clinical guidelines, and benefits to appropriately decision the medical necessity of services requested.
• Research and respond to all medical, dental, and behavioral health appeal requests according to regulatory and accreditation standards and timeframes.
• Collaborate with the Physician Review Units to assist with medical necessity determinations.

Key Qualifications:

• Registered Nurse with an active unrestricted professional Massachusetts Nursing license.
• Comprehensive working knowledge of the healthcare delivery system.
• Excellent organizational and prioritization skills with the ability to problem solve independently and in collaboration with teammates, Physicians, and other associates for appropriate decision making.
• Strong verbal and written communication skills with internal and external customers, relaying decisions accurately and thoroughly.

Education and Experience:

• Registered Nurse with an active Massachusetts Nursing license required
• Associate's Degree in Nursing (ADN) or Bachelor's Degree in Nursing (BSN) required
• Minimum 3-5 years of clinical care experience
• Excellent computer skills

#LI-Remote

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Hingham

Time Type

Full timeHourly Range: $40.71 - $49.75

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.

This job is also eligible for variable pay.

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

We understand that theconfidence gapandimposter syndromecan prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting ourCompany Culturepage. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join ourTalent Communityto stay “in the know” on all things Blue.

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.